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Based on interview and record review, the hospital failed to ensure the Neonatal Intensive Care Unit (NICU) and the Well-Baby Nursery (Nursery) had an adequate number of Registered Nurses to provide nursing care to patients. This is evidenced by having less staff than required by the hospital staffing grid and the Patient Care Manager ' s calculated staffing needs for 44 of 60 shifts in the NICU and 19 of 64 shifts in the Nursery.
Findings:

Review of the hospital policy titled Nursing Policy Manual, Policy #900.5, Revised 7/13 revealed in part:
II. Staffing: B. a. iii. Task nursing occurs when assistance is needed in an area and the nurse being reassigned does not have the competencies to provide total patient care in the reallocated area. In these cases the nurse would be assigned to assist a specific nurse or group of nurses. The decision to institute this level of reallocation would be done when the PCM or nursing supervisor determines that doing so would benefit patient safety and support the nursing staff. In this role the task nurse would not generally provide medication or perform documentation.
Review of the NICU (Neonatal Intensive Care Unit) staffing to patient ratio sheets provided by the hospital revealed in part:
1. Staffing ratios Level III 1:2; Level III step down 1:3; Level II 1:3-4.
2. NICU RN goes to deliveries in place of NNP for uncomplicated cases.
Level III= HFNC (High Flow Nasal Cannulas), Vents, chest tubes and pressure support.
Label III stable= feeders and growers, approx. 1200 grams-gavage, IV fluids, saline lock with meds, NC (nasal cannula) 1 LPM (liter per minute) or less in isolette.
Level II=Feeders and growers- gavage/nipple, IV fluids, saline lock with meds, isolette or O/C (open crib).
Further review revealed the grid also listed the number of RN ' s required in the NICU when the census was 1-24 patients. 2 RN ' s were required when the census was 1-5, 3 RN ' s for a census of 6-8, 4 RN ' s for a census of 9-11, 5 RN ' s for a census of 12-14, 6 RN ' s for a census of 15-16, 7 RN ' s for a census of 17-19, 8 RN ' s for a census of 20-22, and 9 RN ' s for a census of 23-24.
Further review revealed the grid for the Well-Baby Nursery listed the number of RN ' s required when the census was 4-40 babies. 1 RN was required when the census was 4-6, 2 RN ' s for a census of 7-12, 3 RN ' s for a census of 13-18, 4 RN ' s for a census of 19-24, 5 RN ' s for a census of 25-30, 6 RN ' s for a census of 31-36, and 7 RN ' s for a census of 37-40.

In an interview on 8/19/13 at 3:45 p.m. with S2PatientCareManager, she stated the staffing grid for the NICU was determined by herself and the neonatologist and based upon national standards.

A review was made with S2PatientCareManager of the staffing patterns presented by the hospital for the NICU. From 7/21/13 to 8/19/13, the NICU had less staff than required by the staffing grid and S2PatientCareManager ' s calculated staffing needs for 44 of 60 shifts. Review revealed non-task nurses who took a full patient care load was short by 1 nurse on 15 shifts, 2 nurses on 8 shifts, 1-2 nurses on 9 shifts, 2-3 nurses on 7 shifts, 3 nurses on 3shifts and 3-4 nurses on 2 shifts. These findings were verified by S2PatientCareManager on 8/21/13 at 1:30 p.m.

A review was made with S2PatientCareManager of the staffing patterns presented by the hospital for the Well-Baby Nursery. From 7/19/13 to 8/19/13, the Well-Baby Nursery had less staff than required by the staffing grid or S2PatientCareManager ' s calculated staffing needs for 19 of 64 shifts. Review revealed non-task nurses who took a full patient care load was short by 1 nurse for a partial shift on 7 shifts, 1 nurse on 9 shifts, 2 nurses on 5 shifts, and 3 nurses on 2 shifts. These findings were verified by S2PatientCareManager on 8/21/13 at 1:38 p.m.

Review of the Hospital License Application to the Health Standards Section of the Louisiana Department of Health and Hospitals dated 4/28/13 the number of beds listed at capacity was 20 for the Nursery and 20 for the NICU. Review of the patient censuses for the NICU from 7/21/13 to 8/19/13 revealed the capacity was exceeded on 25 of the 30 days. Review of the patient census for the Well-Baby Nursery from 7/19/13 to 8/19/13 revealed the capacity was exceeded on 11 of the 32 days.

Review of the NICU staffing and assignments sheet dated 7/29/13 from 7:00 a.m. until 7:00 p.m. revealed the unit had 28 patients and 7 nurses. Further review revealed each nurse had 4 patients. During lunch breaks, each nurse was assigned another nurses babies to assume care of for 30 minutes. Review revealed 1 of S3RN ' s 4 babies, Patient #1, required having 1 nurse assigned to 2 babies as per the staffing grid because he was on a high flow nasal cannula and was having frequent apnea and bradycardia (cessation of breathing and subsequent decrease in heart rate). In an interview on 8/30/13 at 9:45 a.m. with S2PatientCareManager, she verified S3RN should have only been assigned one other infant with Patient #1 because he was classified as a level III infant. S2PatientCareManager also verified S3RN had 4 infants in 3 separate rooms. She also stated that during lunch breaks, S3RN was assigned to watch S4RN ' s 4 babies which would have given her a total of 8 babies. S2PatientCareManager stated the patient to nurse ratio was unsafe on 7/29/13.

In an interview on 8/19/13 at 11:15 a.m. with S2PatientCareManager, she stated when the nursing staff went to lunch in the NICU, another nurse on the schedule was assigned to watch their babies. S2PatientCareManager verified that when a nurse with a 1:2 staff to patient ratio went to lunch, someone with a1:3 ratio or 1:4 ratio may have assume care of their babies. She said in that case, the nurse would have a 1:5 or 1:6 nurse to patient ratio although she was watching a 1:2 nurse to patient baby. S2PatientCareManager also said when labor and delivery nurses were pulled to the NICU or Well-Baby nursery they were task oriented only and not given a patient assignment. She said in the Nursery the task nurses were responsible for duties such as answering the phone, feeding, changing diapers and bringing babies to their mothers. She said in the NICU, the task nurses assisted with some tasks with stable babies, but the patients were still assigned to a NICU nurse or Well-Baby nurse. She stated they task nurses did not answer alarms, perform assessments or give medications.

In an interview on 8/20/13 at 9:30 a.m. with S2PatientCareManager, she said she has had a problem for the last few months with being short staffed because the hospital had a surge of deliveries. S2PatientCareManager also said the NICU and Nursery nurses were overworked and the staffing was too short. S2PatientCareManager said she asked S4DirMaternalChild several times about transferring babies out to another hospital around 7/20/13. She said around the middle of July, the Nursery had around 30 babies and NICU was also busy also which made the staffing was unsafe in both nurseries during that time period. She said the staffing patterns used in the NICU and the Nursery the last few months did not match the staffing numbers required on the grid. Review of the staffing and census for the Well-Baby Nursery revealed the daytime census was 34 with 3 RN ' s assigned to the patients with 2 task nurses to help. Review of the staffing grid revealed a census of 34 babies in the Nursery required 6 nurses.

In an interview on 8/20/13 at 1:50 p.m. with S3RN, she said for the last year there had been unsafe ratios and assignments in both the NICU and Well-Baby Nursery the majority of the time. S3RN said while working in the Well-Baby Nursery several months ago, she had an 8 baby assignment, 3 of which were transitioning. She said transitional babies required vital signs taken every 30 minutes, feeding, bathing, and transitioning to an open crib from the radiant warmer. S3RN said on that day, her 4th admission had to be transitioned in labor and delivery because the family was given the option to be with the baby during the transition period. S3RN said when she told S5OBPatientCareManager it was unsafe to leave her other babies in the nursery, S5OBPatientCareManager, " bit my head off " . S3RN said the transition in labor and delivery took approximately2 hours which left the other nurses, who were already overwhelmed, with the 3 babies transitioning on the warmers and her other 4 babies. S3RN continued to say that on 7/29/13 she had been assigned Patient #1in the NICU who was a 1:2 nurse to baby ratio. S3RN said Patient #1 desaturated (oxygen saturation dropped) and had bradycardia (decreased heart rate) approximately every 30 minutes during the shift. S3RN said she had 3 other babies in two other rooms, one of which was Patient #2. She said Patient #2 was on the other side of the unit beyond the nursing station from Patient #1 and had a PIV (peripheral intravenous line), TPN (Total Parental Nutrition), Lipids, Phototherapy (light therapy for jaundice) and was starting feeds. She said there was no way to view 4 babies vital signs on one monitor and the other babies were not in sight or sound of her. S3RN also said nobody constantly monitors the central monitor at the nursing station. S3RN said it was unsafe with several babies in that many different rooms, especially when 1 of the babies had constant apneic episodes and bradycardia which required stimulation to recover. S3RN stated she had repeatedly told her manager how dangerous staffing was, but nothing had ever been done to correct the problem. S3RN said there was the great potential for something bad to happen to a baby, but so far the hospital had just been lucky.

In an interview on 8/20/13 at 2:25 p.m. with S4RN, she said the NICU has been short staffed for several months. S4RN said on several days she felt uncomfortable with the patient to staff ratios. She said in addition to a 4 baby assignment, sometimes you could be assigned to attend deliveries which could take 30 min to 1 hour. She said you also have to admit babies and watch other nurses ' babies when they go to lunch. She said the staffing in well baby can get to 13 babies per nurse sometimes. S4RN said on 7/2913, the ratios of patients to babies in the NICU were not safe.

In an interview on 8/30/13 at 2:48 p.m. with S6RN, she said on average the nurse to patient staffing had not been safe in the NICU and Nursery for approximately a year. S6RN said last month, there were days where she could only do the bare minimum of care her babies needed. She said she made S2PatientCareManager aware of her concerns, but most of the time she could not find staff to help. S6RN said Well-Baby staffing was worse than NICU. S6RN said she is also required to go to C-sections (Caesarean) which could take 15 minutes to 30 minutes. She said if a C-section was at the beginning of the shift, she could get behind for the entire shift. S6RN said one day recently she had to go to 5 C-sections along with trying to take care of her 3 babies. S6RN said sometimes the staffing is dangerous.

In an interview on 8/21/13 at 10:30 a.m. with S7RN, she said on 7/19/13 she started the shift in the Well-Baby Nursery with 11 patients and ended up with 15. She said all 3 of the nurses working began the shift with approximately 11 babies. S7RN said they were given a couple of task nurses, but they were not assigned patients. She said transitions, admits, discharges, sick babies, antibiotic babies, medications, and charting cannot be done by the task nurse. In the past month, S7RN said a lot of the shifts seemed unsafe because of the lack of adequate staffing for the number and acuity of the babies. S7RN said she reported staffing issues to nursing supervisors and managers, but administration said they could not find nurses to help. S7RN said recently the NICU had 30 babies and the acuity was too high for the amount of nurses that were working. S7RN said when they are understaffed they had to prioritize and some things such as the required assessments got skipped.

In an interview on 8/21/13 at 10:50 a.m. with S8RN, she said she had worked in the newborn nursery for approximately 4 years. S8RN said when they are given a task nurse to help in the nursery, they can feed, diaper, and transport babies. She said the task nurses don ' t take assignments or chart on the infants so counting them as " equal " staffing because they were RN ' s was not accurate. She said in the last month, several of the shifts have been unsafe because of staffing and acuity of the babies. S8RN said she has had more than 8 babies assigned to her at least 3 times. S8RN said the most she had was 11 or 12 babies assigned to me around 7/19/13. She said she had reported to S2PatientCareManager and various charge nurses about the nurse patient ratios being unsafe. S8RN said she feels at times that she is doing the bare minimums to get by because the unit is so short staffed.

In an interview on 8/21/13 at 11:15 a.m. with S9RN, she said the nursery has too many babies and too high of an acuity for the staffing provided. S9RN said she had been assigned 12-13 babies on a shift within the last month. She said a lot of shifts required her to take a 9 or 10 baby assignment. S9RN said the nursery was unsafe at times when the acuity was high. S9RN said she had reported the staffing situation being unsafe to S2PatientCareManager and S4DirMaternalChild. S9RN said the managers said they were trying to find help, but could not find nurses to cover their needs.

In an interview on 8/21/13 at 1:30 p.m. with S2PatientCareManager, she verified the NICU and Well-Baby Nursery staff had complained that the nurses to patient ratios were unsafe, but she was unable to obtain nurses from agencies. S2PatientCareManager said she discussed transferring patients to other NICU ' s with the physicians, but Hospital " A " would only accept them if they were medically necessary transfers. She said the hospital needed to have a system in place for the next time they had a surge of patients. S2PatientCareManager stated the hospital did not currently have the staffing resources to cover the NICU and Nursery if they increased their numbers to the same levels they had in the past month.